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Bringing mental health of mothers into the spotlight in Africa

In most societies, mothers are the primary providers of care to young children. This is a demanding task and the mental health of a mother is not only essential to her well-being, but that of her child’s physical health, nutrition and psychological well-being. However, most child development programmes do not adequately address maternal mental health.

Recent research has shown that about 20% of mothers in developing countries experience some form of mental health problems during or after childbirth. The United Nation’s Secretary-General António Guterres has recently acknowledged that the issue of mental health remains a largely neglected issue and announced the UN’s commitment to “working with partners to promote full mental health and well-being for all”.

Moreover, professionals in the field are pointing out that the mental health of mothers is critical to the success of the UN Sustainable Development Goals on health, nutrition and gender equality (SDG 3, 2 and 5).

In South Africa, the rate of pregnant and postnatal mothers suffering from common mental disorders (depression and/or anxiety) can reach up to one in three. Many of them are poor, come from disadvantaged communities and face many obstacles in accessing services and care.

Across Africa, the majority of women experiencing challenges to their mental health during the perinatal period (pregnancy and up to one year after the birth) are also exposed to gender-based violence, economic and gender inequalities, physical illnesses (including HIV), complications of childbirth and the stresses of childcare. Suicide has been identified as one of the leading causes of maternal death worldwide.

Unfortunately, health care systems in most African countries are not equipped to deal with the complex health and social challenges faced by most mothers. With competing physical health priorities and constrained resources, mental health care remains seriously neglected.

To challenge the status-quo and to improve the mental health of mothers in Africa, a group of individuals and organisations are working together in the newly established African Alliance for Maternal Mental Health (AAMMH).

AAMMH believes that a multi-sectoral approach is needed to tackle the causes of poor maternal mental health in Africa. The alliance calls for the integration of existing evidence-based interventions for the detection, prevention and treatment of maternal mental health problems into reproductive and child health programmes, supported by mental health services with specialist expertise.

This call for action is very close to the PMHP’s mission to develop and advocate for accessible maternal mental health care that can be delivered effectively in low-resource settings. We have thus become involved with the Global Alliance for Maternal Mental Health (GAMMH) over the past year since its formation and are now a proud founding partner of its first regional off-shoot, the AAMMH.

Together with colleagues in Malawi, we have been preparing for the upcoming launch on the 19 June in Lilongwe, Malawi. Prior to the launch, we will conduct a training workshop with health care providers and managers in maternal, mental and child health. On the launch day itself, we will be delivering a keynote address sharing the experience of the PMHP and will also be conducting a workshop towards establishing strategies for working partnerships across sectors for maternal mental health.

We hope our experience and work in South Africa, and in other low and middle-income countries, will contribute to the development and growth of this pan-African advocacy initiative. At the same time, we look forward to collaborating and learning from advocates, practitioners, trainers and researchers across Africa to strengthen the work we do in South Africa.

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The African Alliance for Maternal Mental Health (AAMMH) is part of the Global Alliance of Maternal Mental Health and works in close collaboration with the Marcé Society African Regional Group.

AAMMH will be officially launched in Lilongwe, Malawi on 19 June 2018. You can follow the event by using the hashtag #AAMMH #GAMMH

Read more about aims and objectives of the AAMMH here.

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Addressing the Maternal Mental Health Diagnosis Gap through screening tools

Source: Maternal Health Task Force blog

Diagnosis gap in Low- and Middle-Income Countries (LMICs)

Despite contributing significantly to maternal deaths and unproductive life years, common perinatal mental disorders (CPMD) often go undetected among women in low-resource regions. This can mean that up to 80% of women remain untreated in such settings. Resource-constrained primary care centers, high patient volumes, lack of recognition by health workers as well as increased task shifting to semi-skilled health workers contribute to this treatment gap. In order to encourage timely identification of CPMD among mothers followed by referrals, antenatal care provision centers are a promising platform in LMICs due to the high level of touchpoints between expectant women and health systems. In South Africa, for example, a mother’s contact rate with any antenatal care facilities is quite high at approximately 91%. […]

Empathic engagement training

Lead author Thandi van Heyningen shares insight into progress and next steps for improving maternal mental health in low-resource settings:

“Where health system resources are scarce, one way of improving detection and improving access to treatment, is to integrate these services into existing, routine, primary health care services using a stepped care approach. Improving detection through routine antenatal screening may provide a vital first step, however there is a need to generate further evidence on the feasibility and acceptability of existing screening tools for use in such settings, and by non-specialist health care workers.”

Read the full paper “Comparison of mental health screening tools for detecting antenatal depression and anxiety disorders in South African women” in the MHTF-PLOS collection on NCDs and maternal health

Suicidal thoughts during pregnancy

Perinatal depression and anxiety are serious mental health problems and are among the leading causes of maternal morbidity and mortality worldwide!

Pregnant women are at higher risk for suicidal ideation and behaviours compared to the general population.

Suicide has been identified as one of the major contributors to the global mortality burden and there is a growing concern over the increase in suicidal ideation and behaviour among pregnant women.

Studies in low- and middle-income countries put the rate of maternal death due to suicide at somewhere between 0.65% and 3.55%. In such cases, risk factors include poverty, lack of support, lack of trust in health systems and coexisting mental illnesses.

Suicidal thoughts experienced during pregnancy can continue beyond the initial postpartum period, affecting the well-being of both mother and child.

More about pregnancy and suicidal ideation in our infographic

Breaking the negative cycle of mental ill-health and poverty during the perinatal period

The negative cycle of mental ill-health and poverty is particularly relevant for women and their infants during the perinatal period. During this time, major life transitions render women more vulnerable to mental illness from social, economic and gender-based perspectives.

Those with the most need for mental health support, have the least access. Overburdened maternal and mental health services have not been able to address adequately this significant unmet need. There have been limited attempts at a programmatic level, to integrate mental health care within maternal care services.

The perinatal period, where women are accessing health services for their obstetric care, presents a unique opportunity to intervene in the event of mental distress. Preventive work involving screening and counselling may have far-reaching impact for women, their offspring and future generations.

Mental health care is a notoriously neglected area – even more so in “healthy” pregnant and postnatal women. The focus on the physical to the detriment of the emotional is particularly felt now against the backdrop of HIV and AIDS. The public health service has been unable to address the mental health needs of women from poorer communities – neither within maternity services nor within mental health services. This is despite a wide body of evidence showing that distress in the mother may have long-lasting physical, cognitive and emotional effects on her children.

Integrating mental health into maternal care in South Africa

The PMHP aims to integrate mental health service routinely, within the primary maternal care environment.
Based at selected government MoU facilities in Cape Town, we offer counselling and support services focused on the emotional wellbeing of pregnant women with a strong focus on postnatal and clinical depression.

Breaking the link between gender-based and intimate partner violence and HIV

Intimate partner violence (IPV) during or before pregnancy is associated with many adverse health outcomes.

Pregnancy-related complications or poor infant health outcomes can arise from direct trauma as well as physiological effects of stress, both of which impact maternal health and fetal growth and development.

Antenatal care can be a key entry point within the health system for many women, particularly in low-resource settings. Interventions to identify violence during pregnancy and offer women support and counselling may reduce the occurrence of violence and mitigate its consequences.

This research will provide much-needed evidence on whether a short counselling intervention delivered by nurses is efficacious and feasible in low-resource settings that have a high prevalence of IPV and HIV.

Source: BMC Health Services ResearchBMC series

Follow the project: BioMed Central

Why we should care about maternal mental health

Empathic engagement with mothers

Image: Graeme Arendse

When I examined Johanna*, I noticed that Johanna was very quiet during the examination. Although everything was fine with the pregnancy, I knew that something was wrong. Johanna had filled in a mental health screening questionnaire, which is routinely offered in our clinic. She had a high score. When I approached Johanna to offer a referral to the PMHP counsellor, she started crying. When I asked what was wrong, Johanna said I can’t talk about it. She did, however, want to see a counsellor.

This is only one of many stories we hear from our nurses and midwifes at at one of our service sites. So why is it important that we train health and social workers and advocate for routine mental health screening in all maternity units in the country?

Read about Johanna’s way out of an abusive relationship and how the counselling empowered her to seek help here

What is perinatal mental health?

Some people may be confused about some of the words used in relation to maternal mental health, like ‘intrapartum’, post-partum’, ‘ante-natal’, ‘post-natal’. The time during pregnancy, may be called the ‘antenatal’ or ‘prenatal’ period. ‘Postnatal’ refers to the time after birth. In the mental health field, postnatal may refer to 6 months or 12 months after the birth. Intrapartum usually refers to the labour and delivery time. ‘Perinatal’ refers to the time from the beginning of pregnancy to the end of the first year after the birth.

It is important not to confuse the ‘baby blues’ with postnatal depression. The ‘baby blues’ occurs in about 60-70% of mothers. Feelings of being overwhelmed and tearfulness occur on the third or fourth day after the birth and these resolve usually within a week. Depression or anxiety are more serious conditions and usually require some form of treatment. Depression or anxiety may occur during pregnancy, after pregnancy or in both time periods. The symptoms of these conditions may be confused with the usual physical symptoms of pregnancy such as sleep and appetite changes, aches and pains, tiredness or changing emotions. However, depression and anxiety affects a person’s mood, thoughts and how they function in most areas of their lives.

‘Psychosis’ is when a person becomes out of touch with reality. Postpartum psychosis is actually rare. It occurs in about 1 in every 1000 women (0.1%) who have a baby. This illness, if rapidly and effectively managed, usually resolves completely so that mothers may return to being well and fully functional.

Find more definitions on perinatal mood disorder here

Why should we care about it?

Perinatal depression and anxiety are significant mental and public health problems with well-documented consequences for mothers, children, and families. In developed countries, suicide is a leading cause of maternal death.

Because of the stigma of mental illness and a lack of understanding, many women who suffer from depression and anxiety, and their families, are not aware that these conditions require treatment (like any other health condition) and that they can be managed (often with relatively simple methods) so that they can recover fully.

Mental health care usually starts with some form of ‘talking therapy’. This can provide the necessary support to empower a women to identify resources and personal capabilities. A therapeutic relationship can enhance a woman’s resilience to difficult life circumstances and support her to nurture her children optimally. Caring for mothers is thus a positive intervention for long-term social development. Many women may also safely benefit from antidepressant medication which effectively treat both depression and anxiety.

How many are affected?

According to the World Health Organisation, worldwide about 10% of pregnant women and 13% of women who have just given birth, experience a mental disorder, mainly depression. In developing countries this is even higher, i.e. 16% during pregnancy and 20% after child birth.

In South Africa, studies show that at least one in every five women suffering during or after pregnancy.

1 in 5 women suffering from depression

Why is mental illness during and after pregnancy so common in South Africa?

Pregnancy and the postnatal period is a psychologically distressing time for many women, particularly for those living in poverty, or with violence, abuse, HIV/AIDS or an unintended pregnancy. Many women in South Africa live in these circumstances.

Several studies on prevalence of common perinatal mental disorders in low and middle income countries are collated on our website.

Who is at risk?

Infographic: Anisha Gururaj and Ashley Pople

Perinatal mental health is connected to a wide range of issues faced by women and although many of the risk factors are common for all women, they can vary from country to country. See the infographic below for comparative risk factors between India and South Africa.

Women in South Africa are particularly at risk when faced by:

  • Domestic violence – violence contributes to poor mental health, and poor mental health makes it more difficult for women to negotiate relationships where there is conflict
  • HIV/AIDS– HIV puts people at greater risk of mental health difficulties, while poor mental health makes it less likely that those who are HIV positive to adhere to treatment
  • Refugee issues– women who are refugees are more likely to suffer mental health difficulties due to their past experiences and to a current lack of support
  • Substance abuse – poor mental health makes women more likely to use substances such as alcohol in an attempt to feel better, but in turn, these substances and the circumstances around using them, lead to worse mental health
  • Teen pregnancy – teenagers with poor mental health are more likely to engage in risky behavior and become pregnant, while pregnancy brings increased social and emotional pressures which then affect mental health

What can we do about it?

Education is key and it is important that mothers and families are sensitized. Informing mothers about perinatal mental health will go a long way in helping them manage depression, anxiety and related illnesses. This education must include information about how to get help and support.

The support may be emotional, practical or financial. Partners should pay attention to the needs of the mothers as well as their own mental health. Seeking help when it is necessary for either or both parents, is a useful way to cope with difficult circumstances. This may be from family, community, health or social workers or faith-based organisations.

Find out where you can receive help in South Africa here

*The PMHP is committed to client confidentiality in keeping with the ethical requirements of professional mental health practice. The client stories reflect common scenarios or sets of circumstances faced by many of our clients. Pseudonyms are used and details are changed. The stories are not based on any one particular woman’s experience, unless an individual explicitly chooses to share her story with or without her name attached.  

New PMH Toolkit offers diverse collection of resources

The Royal College of General Practitioners has launched a new
Perinatal Mental Health Toolkit

The resources are designed to support GPs and healthcare professionals to support and deliver the care patients with perinatal mental health conditions need.

Furthermore it contains resources for mothers, fathers and an entire section on family support, self-care and well-being during and after pregnancy. This includes information leaflets for patients, and links to supporting charities and social media groups.

CaringForFuture

This toolkit offers a comprehensive and holistic approach to tackle the stigma of perinatal mental health problems!

The power of sharing your story – every voice counts #momsmatter #everyonesbusiness

More and more women are sharing their personal story with depression during or after pregnancy.

“Maureen had her first suicidal thought the morning she found out she was pregnant with her first son seven years ago.”
Her documentary Dark Side of the Full Moon
shares her story and the stories of several other women who suffered from postpartum depression.

Rosey is a mum of three, fighter of PND and founder of  She is also considered one of the leading campaigners for improving perinatal mental health services.
Every wednesday everybody can join, follow, and connect with others affected by perinatal mental illness on twitter. She also runs a very successful blog to share her story.

wpid-instaquote-20-04-2015-06-50-561

“Amelie suffered from postnatal depression when her son Zenon”
Inspired her story, a nurse and writer is bringing hard-hitting play Friction to the stage.

Friction

And there are many more inspiring women sharing their stories and raise awareness about perinatal mental health.

Inspiring compassion that will turn into action and one day every women will receive the mental health care they need.

PMHP – in the international arena

Members of the Perinatal Mental Health Project (PMHP) presented to delegates at the International Marcé Society Biennial Scientific Meeting in Swansea and the World Congress of Psychiatry in Madrid last month. Here are some highlights and insights from our two presenters:

Presentation by Director, Simone Honikman

Simone was invited to speak about the PMHP as part of a symposium entitled “Born this Way: finding solutions to global challenges in Perinatal Mental Health”. The symposium convenor, Professor Carlos Zubaran, of the University of Western Sydney, had also arranged for speakers from Norway, Spain, Israel and Portugal to present. The PMHP presentation was unique in that our project was able to present solutions to high levels of depression and anxiety in contexts where resources are limited. The symposium was well attended, generated vibrant discussion as well as potential connections for future collaborations.

Sim_Symposium

Simone Honikman with fellow symposium speakers

Read the abstract of the presentation ‘Maternal mental health and health service design‘ by Simone Honikman here: MMH_abstract

Presentation by Research Associate, Thandi van Heyningen
Research Associate

Thandi’s presentation was about screening for maternal depression and anxiety in a low-resource primary care antenatal setting in South Africa. She spoke about the use of various screening instruments as well as potential psychosocial risk factors. The results of this research from Hanover Park, have shown that a short, binary-scoring screening instrument that is easy to administer and score, performs as well as longer, more complex screening tools in detecting maternal anxiety and depression. The Whooley depression screen, which consists of two questions about mood symptoms and a third “help” question shows promise as a screening tool for the early detection of maternal depression and anxiety in these settings.

Read the abstract of the presentation: ‘Development of a mental health screening instrument for low-resource, primary-care antenatal settings in South Africa’ here: MentalHealthScreening_Abstract

#Marceconf

“Creating Change in Perinatal Mental Health” Apart from Thandi, many speakers inspired at the Marcé Conference (Photo: John Cox after his speech)

PMHP Mid-Year report: hot off the press

We are pleased to share our 2014 Mid-Year report with our partners, friends and supporters. 

This reports highlights some of the key achievements in our four programmes:

Clinical Services,
Teaching and Training,
Research &
Advocacy and Communications.

PMHP_MidYear2014-front

You can Download the PDF version here.
Previous reports can be downloaded on our report pages here
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